GASTROINTESTINAL TRACT Begashaw M (MD)

Gastrointestinal bleeding has high mortality & morbidity persistent bleeding and/or recurrence carries worse outcomes without immediate intervention

DEFINITION UGIB  blood loss proximal to ligament of Treitz LGIB blood loss distal to ligament of Treitz Hematemesis  vomiting of blood Melena passage of black tar stool Hematochezia passage of blood per rectum

UPPER GASTROINTESTINAL BLEEDING Etiology - PUD –commonest ,DU 4x - Varices-cirrhosis, portal hypertension - Gastritis-NSAID - Gastric ca Stress ulcer -trauma, shock, sepsis, burn Mallory-Weiss tear-prolonged violent vomiting - Esophagitis

WORK-UP & MANAGEMENT Immediate intervention Having a clinical suspicion of the possible site History- Collapse - Sweating - Anxiety, restlessness - Large amount of bloody vomitus - Hematochezia/melena

History • Scoiodemographic -Age • PUD hx - past or present • Drugs • Liver disease • Co-morbid diseases • Symptoms of bleeding diathesis

Examination - Rising PR & RR - Decreasing BP & pulse pressure - Restlessness - Increasing pallor - Cold nose and extremities - Sweating - Decreased urine output

Management Insert large bore intravenous cannula Rapid crystalloid infusion Blood transfusion Monitor-VS , urine output Anxiety & pain - diazepam, analgesic NG tube - monitor rate of bleeding,saline lavage

Stabilized -laboratory data ,further treatment Blood transfusion Ixns -Esophago-gastro-duodenoscopy - Medical therapy - Endoscopic therapy - Surgical (operative) - to control the bleeding

LOWER GI BLEEDING DDX - Small intestinal bleeding - Colorectal bleeding - Anorectal bleeding

Small intestinal bleeding Is uncommon rarely massive difficult to diagnose Usually a diagnosis of exclusion

Colonic bleeding Acute & massive chronic  occult blood positive stool & anemia Causes : -Neoplasms /polyps -Diverticulosis/ diverticulitis -Vascular malformations -Inflammatory causes

Anorectal bleeding Causes - Hemorrhoids - Anal fissure - Tumors /polyps - Proctitis

Clinical evaluation Hemodynamic status Hx -Hematocheziamassive UGIB/bleeding from right colon -Chronic bleeding Unexplained anemia Orthostatic hypotension Fatigue/weight loss

Visible bleeding in assosiation with: - Pain - Change in bowel habits- Stool frequency - Stool consistency Excessive mucus discharge per rectum Sense of incomplete defecation Tenesmus - Pruritus - ani

Physical examination Vital sign indices of tissue perfusion signs of chronic blood loss Complete abdominal Exm-DRE pelvic examination-Female

Treatment Resuscitation -first priority - NG tube lavage to exclude UGIB - CBC -WBC, HCT/Hb, platelet count - Esophago-gastro-duodenoscopy (EGD) - Blood chemistry - Coagulation profile - Stool examination - Lower GI Endoscopy Procto-sigmoidoscopy

COLORECTAL TUMOUR Colorectal carcinoma-common causes of death Symptoms are largely nonspecific Mortality & morbidity-GI bleeding & acute abdomen High index of suspicion-Very important

COLORECTAL CARCINOMA common second commonest cause of death Usually over 50 years of age F>M Sigmoid/rectummost frequent site

Pathology Macroscopic -Polypoid -Malignant ulcer -Annular -Tubular Microscopically -Adenocarcinoma

Predisposing factors -pre-existing polyps -Familial adenomatous polyposis -Ulcerative colitis

Spread Local spreadSlow growth Lymphatic spreadRegional LNs Blood streamliver /lungs/skin/bone Trans-coelomicmalignant deposits peritoneal cavity & to non-adjacent organs

Clinical features Right colon - Anemia - Loss of appetite/weight loss/ generalized body weakness - Palpable lump

Left colon - Change in bowel habit - Passage of mucus - Tenesmus /sense of incomplete defecation - Rectal bleeding - Intestinal obstruction - Pain-> late - urinary: due to pressure /invasion

Investigations S/E - Parasites, WBC, occult blood, culture Sigmoidoscopy colonoscopy Barium enema Biopsy under endoscopic guide

Staging investigations Ultrasonography Chest x-ray Liver function test

Management depends on - mode of presentation - stage of the disease site of the primary lesion - presence or absence of multiple lesions

Modalities Surgery - Emergency laparotomy - bleeding , acute abdomen - Elective surgery After pre-operative colon preparation Resection for resectable tumors (curative) - Palliative: palliative surgery, Cytotoxic chemo therapy, Radiotherapy

ANORECTAL ABSCESSES In association with underlying systemic or local diseases - AIDS, Diabetes mellitus, rectal tumors, inflammatory bowel disease Complications fistula in ano - sepsis perianal sepsis

Pathogenesis Caused by mixed micro organisms Infection of anal gland spreads along tissue planes Risks -Perianal hematoma -Perianal injurie -extension from cutaneous boils

Classification Perianal-subcutaneous abscess -commonest type Ischiorectal abscess -also common -located in ischiorectal fossa Sub mucous abscess -located under the mucous membrane Pelvirectal abscess -located above levator ani -follows spread from pelvic abscess

Anorectal Abscess

Clinical features Pain -severe, fever Constitutional –sweating/anorexia Constipation Lump visible/tender /brownish induration Rectal tender mass

Management Drainage Irrigation Packing with saline soaked gauze Sitz bath twice daily Antibiotics if systemic manifestations in immunocompromised Analgesics /mild laxatives

Perianal abscess drainage

PERIANAL FISTULAS (FISTULA IN ANO) is a track, lined by granulation tissue, which connects the anal canal or rectum internally with the skin around the anus externally

Risk factors Untreated /inadequately treated anorectal abscess Granulomatous infections IBD -multiple external openings Tuberculous proctitis Crohn’s disease

Classification Low  internal opening below anorectal ring High internal opening at/above anorectal ring

Fistula in ano

Classification

Goodsall's Rule

Clinical features Seropurulent discharge perianal irritation - External opening  small elevated opening with a granulation - Internal openingfelt as a nodule on DRE - Signs of underlying/associated dss

Management - Emergency treatment for abscesses - Treatment of underlying cause - Surgery for fistula in ano - Preceded by Preoperative bowel cleansing (enema) Examination under anesthesia

Surgery Low level fistula -fistulotomy/fistulectomy -Wound care High level fistula -Protective colostomy to prevent infection and facilitate healing -Staged operation

ANAL FISSURE (FISSURE IN ANO) Elongated tear in the lower anal canal Upper end stops at dentate line Located commonly in the posterior midline Occasionally along the anterior midline

Etiology is not completely understood Passage of hard fecal mass precipitates & aggravates the condition

Classification Acute fissure: deep skin tear at the anal margin extending in to the anal canal with edges showing little inflammatory indurations /edema is accompanied with spasm of the anal sphincter muscle Chronic fissure:Inflamed and indurated margins as a result of inflammatory fibrosis and contracture of the internal sphincter

Clinical features - Pain - commonest - sharp, severe pain starting during defecation and lasting an hour - Constipation - Bleeding-bright streaks on the stool surface/toilet paper Discharge

Examination - Tightly closed anus - sphincter spasm - skin tag -visible at anal verge - Lower end of fissure on gentle parting of buttocks DRE - local anesthetic gel - Vertical crack in the anal canal

Management Conservative management small acute/ superficial fissure - high fiber diet - high fluid intake - mild laxative-liquid paraffin - Local anesthetic ointment/suppository

Surgery Lateral anal sphincterotomy Fissurectomy /sphincterotomy  used for cases with a chronic fissure _ complications- hematoma formation - incontinence -mucosal prolapse POP care: bowel care, daily bath and softening the stool till wound healing

HEMORRHOIDS (PILES) are dilated sub mucosal veins in the anus Classification _Internal -Internal to the anal orifice _External -External to the anal orifice _Interoexternal- Prolapsing internal hemorrhoids

INTERNAL HEMORRHOIDS dilatation of the sub mucosal internal venous plexus and draining superior hemorrhoidal veins develop within areas of enlarged anal lining (anal cushions’) In lithotomy position- three groups _3, 7 & 11 o’clockcorresponds to distribution of superior hemorrhoidal vessels (2 on the right,1 on the left)

Etiology idiopathic underlying causes - Straining accompanying constipation - Straining at micturition - Recto Sigmoid mass

Clinical features usually asymptomatic Rectal bleeding-earliest, bright red painless Prolapse of varicose masses mucoid discharge Pruritus ani Pain Anemia

Grading First degreedo not prolapse out side Second degree prolapse on defecation but reduce spontaneously Third degreereplaced manually/stay reduced Fourth degreeremain permanently prolapsed outside anal margin

Examination Abdominal/pelvic examination - underlying causes aggravating factors Rectal examination _prolapsing hemorrhoids (piles) _redundant skin folds/skin tags _prolapsing /thrombosed

Investigations Proctoscopy- to visualize internal hemorrhoids & exclude other lesions

Complications Hematochezia Strangulation-acute pain Thrombosis- swollen, dark, tense & feel solid / tender Ulceration Gangrene - infection/sepsis Abscess formation

Management Conservative measure - High fiber-diet - Hydrophilic creams /suppositories - Local application of analgesic ointment /suppository - pregnancy and post partum hemorrhoids

Operative treatment Hemorrhoidectomy - Third degree hemorrhoids - Failure of conservative Mx - Fibrosed hemorrhoids - Intero external hemorrhoids

Treatment of CXN Strangulation/thrombosis /gangrene -Immediate surgery -antibiotic coverage -pain relief -bed rest, frequent hot sitz bath -warm saline compress

EXTERNAL HEMORRHOIDS Thrombosed external hemorrhoid - is usually associated with pain appear inflamed tense tender & easily visible Treatment Analgesics Avoid constipation Surgical evacuation of clot

Surgical drainage of thrombosed hemmoroid